A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?
Client report of intense feeling of heat in the fingers
Pallor of the toes with cold exposure
Feet that become reddened with ambulation
Swelling of the joints of the fingers
The Correct Answer is B
A. This is not typical for Raynaud's phenomenon. Instead, Raynaud's is characterized by episodes of reduced blood flow to the extremities, often triggered by cold or stress, leading to sensations of coldness or numbness rather than warmth.
B. This finding aligns with Raynaud's phenomenon. During an episode, the blood vessels constrict in response to cold or stress, leading to pallor (whiteness) in the affected areas, such as the toes and fingers. This is a classic symptom of the condition.
C. While feet can become reddened due to increased blood flow after rewarming or after exposure to warmth, this is not a characteristic feature of Raynaud's phenomenon. In Raynaud's, the affected areas typically exhibit color changes from white (pallor) to blue (cyanosis) and then red (hyperemia) as blood flow returns, but redness upon ambulation is not specifically indicative of the phenomenon.
D. Swelling of the joints can occur in SLE due to arthritis or inflammation but is not a direct symptom of Raynaud's phenomenon. Raynaud's primarily affects blood flow and does not inherently cause joint swelling; however, a client with SLE may experience joint symptoms due to other underlying inflammatory processes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This is incorrect because the time limit is shorter than 30 minutes.
B. This is also incorrect. You need to start the transfusion sooner than this timeframe.
C. You should start the transfusion within 15 minutes after the blood product is issued from the blood bank. This guideline is critical to minimize the risk of bacterial growth and ensure the safety of the transfusion.
D. The time limit is shorter than 60 minutes, emphasizing the urgency in starting the transfusion to maintain the integrity of the blood product.
Correct Answer is C
Explanation
A. In iron deficiency anemia, serum iron levels are typically low due to a deficiency in iron. Additionally, the Mean Corpuscular Volume (MCV) is often low because the red blood cells produced are smaller than normal (microcytic).
B. Similar to option A, serum iron levels in iron deficiency anemia would be low, not high. The MCV may be low or normal, but it would not be high due to the production of microcytic red blood cells.
C. In iron deficiency anemia, TIBC is usually high because the body is trying to maximize iron transport in response to low iron levels. Serum iron is low, and the MCV is low due to the production of smaller red blood cells.
D. This option is incorrect because option C accurately describes the expected lab results in iron deficiency anemia.
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